BASICS

DESCRIPTION

Birth trauma to the eye is a result of ocular, adnexal, or facial injuries due to mechanical forces during childbirth.

EPIDEMIOLOGY

Incidence

• 6–8 injuries (ophthalmic and nonophthalmic) per 1000 live births

• 2% of neonatal deaths and still births are due to traumatic injury at the time of birth

RISK FACTORS

• Large baby size:

– Especially >4500 g

– May be seen in a mother with gestational diabetes

• Instrument assisted deliveries:

– Forceps and vacuum assisted

– Abnormal or excessive traction during delivery

• Prolonged labor:

– Use of induction medications to promote stronger contractions

– Vaginal breech delivery

– Cephalopelvic disproportion (when a baby’s head or body is too big to fit through the mother’s pelvis), maternal pelvic abnormalities

– Oligohydramnios (deficiency of amniotic fluid)

GENERAL PREVENTION

• One can consider caesarean section as an alternative to vaginal deliveries when there is a high risk for the need for obstetric instrumentation.

– Does not guarantee an injury free birth and can pose different or additional risks to the newborn and mother.

PATHOPHYSIOLOGY

Visual deprivation in affected eye due to amblyogenic insult such as irregular astigmatism or ptosis

ETIOLOGY

• Primary trauma to the eye or ocular adnexa

• Secondary ocular injury due to central nervous system, cranial nerve, vascular, or facial bone injuries

COMMONLY ASSOCIATED CONDITIONS

• Midcavity forceps

• Vacuum extraction

• Fetal macrosomia

• Abnormal presentation

• Prolonged labor

DIAGNOSIS

PHYSICAL EXAM

• Pertinent features of birth trauma relating to ophthalmic involvement include:

– Vertical or oblique breaks in Descemet’s membrane of the cornea due to forceps injury at birth

– Asymmetric red reflex

– Eyelid soft tissue ecchymosis, abrasions, or lacerations

– Conjunctival chemosis

– Subconjunctival hemorrhage

– Retinal hemorrhage can be seen in the setting of head injury during delivery such as intracranial hemorrhage or skull fracture. This may result from instrument assisted deliveries.

– Cranial nerve exam: Facial nerve palsy suggested by inability to close the eyelid on the affected side or facial asymmetry during crying.

– Ptosis may result due to multiple underlying causes including: (1) mechanical, i.e., soft tissue ecchymosis; (2) neurologic, i.e., injury to sympathetic chain or cranial nerve III; (3) aponeurotic ptosis, i.e., traumatic levator dehiscence.

DIAGNOSTIC TESTS & INTERPRETATION

Imaging

Initial approach

Consider neuroimaging if neurologic symptoms are present

Follow-up & special considerations

Consultation with a pediatric ophthalmologist

Pathological Findings

Histologic examination of corneal birth trauma typically reveals vertical or oblique breaks in Descemet’s membrane.

DIFFERENTIAL DIAGNOSIS

• Corneal trauma with or without Descemet’s membrane tear

• Corneal abrasion

• Conjunctival chemosis or laceration

• Subconjunctival hemorrhage

• Eyelid laceration

• Cranial nerve injury affecting eyelid function

TREATMENT

ADDITIONAL TREATMENT

General Measures

• Directed to the underlying diagnosis:

– Descemet’s tear: Can result in corneal hydrops (edema and clouding). Generally resolves within weeks with observation alone. Monitor for corneal scarring and visual deprivation.

– Abrasions and lacerations: Careful cleaning, application of antibiotic ointment, and observation. Steri-strips may be used or lacerations may require suturing. Lacerations involving the canalicular system (for tear drainage) warrant consultation with an oculoplastics specialist for surgical reconstruction and repair

– Facial nerve palsy: Management consists of preventing exposure keratitis by protecting the open eye with frequent lubrication with ointment and artificial tears, and if necessary, limited patching.

– Ptosis: Directed to the underlying cause initially. Various surgical techniques can be utilized in order to prevent deprivation or refractive amblyopia.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

• Early pediatric ophthalmology referral for evaluation and treatment of amblyogenic conditions

• Frequency dictated by underlying condition

PROGNOSIS

Excellent if amblyogenic causes are detected and treated early

COMPLICATIONS

• Amblyopia due to visual deprivation

• Ptosis

• Exposure keratopathy

ADDITIONAL READING

• Moczygemba CK, Paramsothy P, Meikle S, et al. Route of delivery and neonatal birth trauma. Am J Obstet Gynecol 2010.

• Schullinger JN. Birth trauma. Pediatr Clin North Am 1993;40(6):1351–1358.

CODES

ICD9

• 371.33 Rupture in descemet’s membrane

• 772.8 Other specified hemorrhage of fetus or newborn

• 767.8 Other specified birth trauma

CLINICAL PEARLS

• Breaks in Descemet’s membrane may result from forceps injury.

• Frequent ocular lubrication to prevent exposure keratitis is a must in cases of facial nerve injury.

• Monitor babies for amblyopia; visual prognosis is generally excellent.

Stay updated, free articles. Join our Telegram channel

Join